Mar 27 2012
I know a woman who is a survivor of colorectal cancer. At one point, doctors had given up hope and put her in hospice, but she failed to die as predicted and was eventually discharged. She continues to suffer intractable symptoms of pain with alternating diarrhea and constipation. I don’t have access to her medical records, but she tells me her doctors have talked about irritable bowel syndrome (IBS) and have also suggested that the heavy doses of radiation used to treat her cancer may have caused permanent damage to her colon. Whatever the cause, her symptoms have seriously interfered with her mobility and her quality of life. Her health care providers have recently recommended questionable treatments in what I think can be construed as using CAM as a dumping ground for difficult patients.
Colonoscopy hadn’t shown any obstruction, but one of her doctors had hypothesized that her symptoms might be due to impaired bowel motility in the irradiated area. She was desperate enough to consider surgery if there was a chance that bowel resection or colostomy might improve her symptoms. She belongs to a large, well-known HMO with a good reputation. She asked her primary HMO physician who thought the idea was plausible and referred her to a surgeon. The first surgeon said surgery was not indicated and referred her to another surgeon on staff. In addition to being board certified in general surgery, the second surgeon was allegedly board certified in something related to CAM (my friend can’t remember his exact words and has been unable to verify any such credentials online).
The surgeon recommended acupuncture, not once but twice. My friend’s husband (who teaches statistics at a nearby community college) told the surgeon that he was fascinated by the challenges of double-blinded studies of acupuncture and that he was aware of no benefits beyond the placebo level. The surgeon then retreated a little and suggested that the primary benefit of acupuncture in treating IBS was the “relaxation” effect.
They asked about referral to a dietitian and the surgeon made some very negative comments about dietitians, saying they were “too conventional” for his taste and were in thrall to the department of agriculture. In addition to her current treatment, he prescribed the probiotic Fortefy, digestive enzymes (Source Natural), and fiber: whole psyllium husk titrated to produce BM’s like ripe banana. There is some evidence to support probiotics and fiber for IBS, but it is far from conclusive. I couldn’t find any evidence that digestive enzymes taken orally are effective in IBS, and I don’t understand why he would recommend a diet supplement product over a prescription enzyme preparation designed to resist destruction by the digestive process. Moreover, if three new treatments are started at once and the patient improves, there is no way to tell which (if any) is responsible: if only one of the three was effective, the patient might end up unnecessarily continuing to use two ineffective treatments.
The patient then made an appointment with a dietitian on her own initiative. The dietitian gave her a big spiel about an inflammation-free diet and gave her several handouts. One of the handouts offered this overly simplistic justification for the diet:
Inflammation and Anti-inflammation compounds are produced in our body from the food we eat. Pro-Inflammation is Omega-6 and Anti-Inflammation is Omega-3. The US diet contains way too much omega-6 (20/1 ratio which should be about 2/1). We eat too much grains (omega-6) and not enough veggies and legumes (omega-3). Even the cattle we eat are primarily grain fed as is farm fish. This all results in too much inflammation in our body. Heart disease is promoted by excess inflammation.
It recommended monitoring inflammation levels with a C-Reactive Protein (CRP) test, saying “It is now the standard test.” (Sez who? Standard for what? Validated by whom?)
Note: CRP is a marker of inflammation whose clinical usefulness is limited. It rises in many conditions including pregnancy, infections, burns, and rheumatoid arthritis. it has been associated with atherosclerosis but it is not independently useful for predicting heart attacks. Dietary and other interventions may lower CRP, but the “anti-inflammatory diet” has not been tested for this, and we don’t have any evidence that just lowering CRP alone would result in better health.
Another handout recommended monitoring inflammation with a complex “IF” rating that supposedly incorporates more than 20 pro- and anti-inflammatory factors. A separate, several-page handout listed the IF numbers for a long list of foods. The IF rating was apparently a solo invention of Monica Reinagel, a nutritionist who wrote The Inflammation Free Diet Plan. As far as I could determine, it has never been validated or shown to have any clinical usefulness.
Another handout gave a Rainbow Remedy Recipe for cooking a mixture of beans, nuts, and colorful vegetables. Another handout was an extensive list of foods containing phytochemicals that “might help decrease the risk of cancer.” For example, the allyl sulfides in garlic and onions “may block the action of cancer-causing chemicals.” (Yes, they “may,” but does that mean eating those foods will actually reduce your risk of cancer?)
I had to laugh at the handout entitled “Fred’s Diet Plan.” Who is Fred and why should we eat like him? (I’m guessing it was extracted from Reinagel’s book, since it ends “Recipes…see pages 90-137”).
One thing really set off the alarm bells.The HMO has a secure e-mail system that it normally uses for all communications between providers and patients. The dietitian asked for the patient’s personal e-mail and sent the information to it, saying she couldn’t send the information through the HMO’s e-mail system. She didn’t make the reason clear, but it sounded to the patient like she didn’t want others at the HMO to know what she was recommending.
Responding to Frustrations?
My friend got the impression that her doctors felt frustrated because they had nothing to offer her, so they found it convenient to foist her off on an acupuncturist and suggest questionable treatments just to get her out of their hair. Did they care whether she was being given science-based information or was being baffled with bullshit? Did they believe she would benefit from some kind of placebo response? Did the HMO management know what was going on in their institution? Do they approve of the surgeon claiming expertise in CAM? Do they approve of their dietitian recommending the anti-inflammatory diet? Does she recommend it to every patient?
In a novel I read long ago, an intern said he had put an obnoxious patient’s bed in “the orthopedic position.” When asked what that meant, he said you put the bed as high as it will go and hope the patient will fall out and break something so you can transfer him to the orthopedic service and be rid of him. That was fiction, but the reality is that every doctor has difficult patients he dreads seeing on his appointment list, sometimes because they are obnoxious but often because their symptoms are stubbornly resistant to treatment and he knows he has nothing more to offer them. Referring them to an acupuncturist would be an easy way out, a way to reduce stress and to avoid guilt feelings for being unable to help those people. Surely that is a natural temptation.
“Integrative” medicine is another tempting way out. When science-based medicine has little or nothing to offer, the “integrative medicine” concept is seductive. It allows you to step outside the constraints of the scientific arena. In CAM there are no rules because there’s no solid evidence to base rules on; you can pretty much try anything that occurs to you, and just make things up as you go.
We have talked a lot about why patients use CAM. We have not talked as much about why some doctors are drawn to it. I suspect the “difficult patient” dilemma is one of the reasons. Once started, using questionable treatments is self-reinforcing:
- If it doesn’t work, the patient may give up on you and never come back to bother you.
- If the patient never comes back, you can assume your treatment worked and he didn’t need to come back.
- If a patient doesn’t improve, you can rationalize:
- You can remember the others who did improve and convince yourself that it works most of the time and that the current patient is an exception.
- You can persuade yourself that it’s the patient’s fault for not following your instructions to the letter.
- You can imagine that the treatment would have worked if only the patient had come to you in time, earlier in the course of the illness.
- You can tell yourself you were right, but not quite right enough; and you can devote many more appointments to tweaking your recommendations.
- Most patients will improve over time, just from the natural course of the disease or from other unrecognized confounding factors, and you can take the credit.
- Patients who improve will give you the credit and tell you what a wonderful doctor you are.
Are doctors using CAM and integrative medicine as handy dumping grounds for difficult patients? I’m guessing that’s one reason for their increasing popularity.
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